Multiaxial Assessment - MH

Question 1

Multiaxial Assessment

Answer 1

Facilitates comprehensive diagnostic picture of:

• Mental disorders
• General medical conditions
• Psychosocial problems
• Environmental problems
• Level of Functioning
• Most of which would be missed with a “single” diagnosis.
• Also provides for the use of a biopsychosocial model for conceptualizing mental disorders.

Question 2

Axis I-V

Answer 2

• Axis I: Primary Clinical Disorders and Other Conditions That Need Clinical Attention.
• Axis II: Personality Disorders and Mental Retardation. + learning disabilities
• Axis III: General Medical Conditions. +obesity, cardiac disease
• Axis IV: Psychosocial and Environmental Problems.
• Axis V: Global Assessment of Functioning Scale (GAF).

Question 3

Axis I: Clinical Disorders Focus of Clinical Attention

Answer 3

• All of the various disorders except Personality Disorders and Mental Retardation and learning disabilities
• Chief complaint and principle diagnosis
• If more than one Axis I diagnosis, all should be reported
• Best to also label the “principal diagnosis” or “reason for visit”
• If more info is needed to make an Axis I diagnosis, code: Deferred (799.9)
• If no Axis I diagnosis is warranted, code: None (V71.09)

Question 4

Axis II: Personality Disorders and Mental Retardation

Answer 4

• Axis II notes “prominent maladaptive personality features and defense mechanisms”.
• Having a separate axis for these concerns “ensures that consideration will be given to the possible presence of Personality Disorders and Mental Retardation” that would otherwise be overlooked in a single-axis diagnostic schema.
• Note: Borderline Intellectual Functioning is also coded on Axis II
• Even if Axis I diagnoses are “more florid” Axis II diagnoses are equally important.
• If more info is needed to make an Axis II diagnosis, code: Deferred (799.9)
• If no Axis II diagnosis is warranted, code: None (V71.09)

Question 5

Severity

Answer 5

For Axis I and Axis II, can code severity either in some diagnostic categories (e.g., mental retardation) or using specifiers:

• Mild: meets criteria for the diagnosis; however, few additional symptoms
• Moderate: “between Mild and Severe”
• Severe: either has many more symptoms than required for a diagnosis, some of the symptoms are particularly severe (e.g., suicide attempt), or daily functioning (school, work, family) is severely affected.

Can also note the following for Axis I or Axis II:

• In Partial Remission: patient no longer meets full diagnostic criteria; some symptoms may still remain.
• In Full Remission: patient has been free of symptoms for an extended period of time.
• Prior History: patient no longer meets criteria for this diagnosis; however, it is clinically prudent to include this diagnosis.

Question 6

Rule - Outs

Answer 6

• Suppose you assess a patient and believe a diagnosis is warranted; however, you do not have enough assessment data to confirm the diagnosis.
• However, to not diagnose this “hunch” would not communicate the clinical picture of the patient effectively.
• You may consider using a “rule-out” diagnosis: R/O in place of the actual diagnosis.

Question 7

Axis III - General Medical Conditions

Answer 7

-These should be “potentially relevant to the understanding or management of the individual’s mental disorder.”

Primary purpose of Axis III:

• “to encourage thoroughness in evaluation”
• “to enhance communication among health care providers”

Differential diagnostic issue:

• If a general medical condition is a direct physiologic cause of a mental disorder, it is coded on Axis I and Axis III.
• Axis I: Mood Disorder Due to Hypothyroidism
• Axis III: Hypothyroidism
• Medical conditions can influence choice in pharmacotherapy.
• If multiple diagnoses are present on Axis III, code them all.
• If no diagnosis is present, code “None”.
• Notes: Numerical codes for Axis III come from the ICD-9 (or ICD-10), No numerical code for “None”.

Question 8

Axis IV - Psychosocial and Environmental Problems

Answer 8

Biopsychosocial model:

• Axis III + Axis I + Axis II + Axis IV
• These are typically a negative life event, an environmental difficulty or deficiency, familial or interpersonal stress, poor social support or personal resources.

Examples:

• Problems with the primary support group: Death of a family member
• Problems related to the social environment: Difficulty with acculturation
• Educational problems: Discord with teachers
• Occupational problems: Unemployment
• Housing problems: Homelessness
• Economic problems: Insufficient welfare support
• Problems with access to health care services: Inadequate health insurance
• Problems related to interaction with the legal system: Incarceration
• Other psychosocial and environmental problems: War, natural disasters

Question 9

BioPsychoSocial Model

Answer 9

Biological

• Physiological/anatomical
• Neurotransmitters
• Genetic Factors
• Gender
• Age
• Ethnicity

Psychological

• Subjective perceptions
• Personality predisposition and their unique thoughts
• Feelings and behaviors
• World view – pessimism, their own personality (axis II)

Social

• Family
• Friends
• Societal Expectations and available services
• Cultural background and environment

Question 10

Axis V - Global Assessment of Functioning

Answer 10

• Clinical judgment involved in Axis V
• “How is the patient doing, overall.”
• 100-point scale, divided into 10 ranges
• GAF – adult scale
• CGAS (Children’s Global Assessment Scale) – GAF adapted for children
• Can also report the time period that the rating encompasses: Current, highest over past year, at admission, at discharge

Question 11

Example: Multiaxial Diagnosis

Answer 11

Axis I: Major Depressive Disorder
Axis II: Borderline Personality Disorder
Axis III: Thyroid disease
Axis IV: Problems with primary support group: marital separation
Axis V: GAF = 60 Moderate difficulty in social and occupational functioning